Copyright 2011 Right Care How Right Care can support CCGs to get value for patents and populations Professor David Colin-Thomé Independent Health Care Consultant Member of the Right Care team, Department of Health k Commissioning for Value

2 CHANGE; Both the bureaucracy and the market have a part to play but what is needed are complex adaptive systems because healthcare is too complex to be managed through the market or bureaucracy alone

3 Liberating the NHS…or bamboozling? “Design an approach to moderation, conditions and decisions that is consistent, proportionate, transparent, and legally compliant, supporting the delivery of an efficient and consistent decision-making process. The process design will be accompanied by template documents and conditions to further support efficiency and consistency. This rigorous approach will also protect both the NHS Commissioning Board (NHS CB) and CCGs by ensuring that the risks of CCGs taking on responsibilities before they are ready to do so are minimised, whilst maximising the opportunities for full authorisation.” “One reason for the conditions will be that groups are required to demonstrate strong and “credible” operational and service planning for , including how they will achieve financial balance. Few CCGs are in a position to do so and no framework or guidance is yet in place.”

4 A changing paradigm 21 st Century Health Care Patient-centred Focus on prevention of disease & harm Reduce waste and increase value Patient as co-producer Equitable care for populations Focus on systems Operates through networks Driven by knowledge Low carbon usage Challenges met by transformation 20 th Century Health Care Clinician-centred Focus on benefits of treatment Increase quality Patient as passive complier Good care for known patients Hospital as focus Operates through bureaucracy Driven by finance High carbon usage Challenges met by growth

Free 1980’s Effectiveness 1990’s Cost-effectiveness 2000’s Quality and Safety 2010 and for the rest of the century VALUE

6 Right Care - Commissioning for Value “Value in any field must be defined around the customer, not the supplier. Value must also be measured by outputs, not inputs. Hence it is patient health results that matter, not the volume of services delivered. But results are achieved at some cost. Therefore, the proper objective is.. the patient health outcomes relative to the total cost (inputs). Efficiency, then, is subsumed in the concept of value. ” Source: Porter ME. (2008) What is Value in Health Care? Harvard Business School. Institute for Strategy and Competitiveness. White Paper. “Value in any field must be defined around the customer, not the supplier. Value must also be measured by outputs, not inputs. Hence it is patient health results that matter, not the volume of services delivered. But results are achieved at some cost. Therefore, the proper objective is.. the patient health outcomes relative to the total cost (inputs). Efficiency, then, is subsumed in the concept of value. ” Source: Porter ME. (2008) What is Value in Health Care? Harvard Business School. Institute for Strategy and Competitiveness. White Paper.

7

8 Value = Outcomes / Costs Outcome = Good – Bad (Outcome= Effectiveness – Harm)

9 The Right Care Programme Right Care is a programme designed to increase the value from the resources allocated to healthcare We do this by: Highlighting un-warranted variation in quality, outcomes, activity and spend Empowering patients through shared decision making Engaging clinicians and commissioners to shift from “rationing” to “rational commissioning” Using information to create insights leading to action and ensuring these insights are shared

10

11 The six domains underpinning Right Care

12 Highlighting un-warranted variation in quality, outcomes, activity and spend

13 Variations in healthcare Variations in healthcare exist for many legitimate reasons. Populations and individuals have distinct needs, and some of the variation observed is a reflection of the responsiveness of the service to meeting particular needs. However, the degree of variation demonstrated for instance in the Right Care Atlas of Variation cannot be explained solely on that basis. Unwarranted variations are driven not by the needs of the patient but by the limitations of the healthcare system and the healthcare professionals within it.

14 Reducing unwarranted variation to increase value and improve quality “ A good map is worth a thousand Words… … cartographers say, and they are right: because it produces a thousand words: it raises doubts, ideas. It poses new questions, and forces you to look for new answers. ” Franco Moretti (1998) Atlas of the European Novel 1800–1900 The NHS Atlas of Variation 2011

15 Right Care Themed Atlas Series Child and Maternal Health (Out now) Diabetes Care (Out now) Kidney Care (Out now) Respiratory Disease (Out now) Organ Donation and Transplantation (Dec) Liver Disease (Dec) Diagnostics (Jan 2013) … 2013/14? Themed atlases focus on specific conditions or populations in more depth and are developed as collaborations with key stakeholders

16 Examples of Variation in Child Care Breastfeeding: There is a three-fold variation in breastfeeding rates for babies aged 6-8 weeks across the country. Asthma: Variation in the treatment of child asthma has got worse. In 2008/09, there was a four-fold variation in the rate of children admitted for emergency hospital treatment – now, that has risen to a five-fold variation. Epilepsy: There is a four-fold variation in the emergency admission rate for children with epilepsy. A&E: There is a 3.5-fold variation in A&E attendance for children aged 0-4. Diabetes: There is a 2.6-fold variation in the percentage of children with diabetes admitted to hospital for diabetic ketoacidosis – a serious emergency condition that can lead to coma or even death if Type 1 diabetes is not properly managed

17 In print You can order free printed copies using the online form on our website Online High and Low resolution PDFs are available for download Interactive A fully interactive InstantAtlas tm is available online

18 Empowering patients through shared decision making

19 Patient Decision Aids – empower patients, get better decisions International evidence suggests a 20 per cent reduction in ‘discretionary surgery’ when Patient Decision Aids are used (Cochrane Collaboration review) Research from the Ottawa Hospital Research Institute also states that patients who don’t have decision support: Are 59 times more likely to change their mind Are 23 times more likely to delay their decision Are five times more likely to regret their decision Blame their practitioner for bad outcomes 19% more often

20 Decision Aids reduce rates of discretionary surgery RR=0.76 (0.6, 0.9) O’Connor et al., Cochrane Library, 2009

21 Engaging with clinicians and commissioners to shift from “rationing” to “rational commissioning”

22 “Dis-investment” to fund innovation? There has been controversy surrounding “rationing” in the NHS, with PCTs challenging the use of a range of interventions, sometimes deemed to be of “low value”, and developing clinical policies to reduce the level of interventions, Right Care supports the shift from lower to higher value interventions to provide the “innovation fund” – achieving consensus around that is however difficult. Right Care is working with the Royal College of Surgeons and the Federation of Specialist Surgical Associations to develop Commissioning Guidance. Surgical Commissioning Guidance will support CCG’s to commission evidence-based, cost effective care for patients with conditions amenable to surgical intervention

23 We will do this by… the description of evidence based high value care pathways highlighting variation in the provision of surgical services describing process and outcome measures that allow commissioners to make intelligent commissioning decisions providing levers for change within the local healthcare community links to patient and clinician facing information, and practical examples of high value care pathways that have been implemented in other healthcare communities identifying priority areas for research

24 Procedures Explorer To support the development work for guidance production, Right Care has commissioned East Midlands Quality Observatory to develop a Procedures Explorer Tool and populated it with national SUS data. The tool can be used: By commissioners to understand how commissioning actions can influence variation in spend and outcomes at a granular level By providers to understand how their behaviour can influence outcomes, which may be different from those of other providers across the country The PET will be available online in early 2013.

25 Using information to create insights, leading to action and ensuring these insights are shared

26 NHS Right Care have previously produced “Health Investment Packs” for each of the 151 Primary Care Trusts in England. The packs used available health investment tools to highlight areas where outcome was poor compared with spend, and with other similar PCTs.

27 Information Available for Commissioners The products available to commissioners including: Programme Budgeting Spreadsheet; SPOT (Spend & Outcome Tool); Programme Budgeting Atlas; NHS Comparators. Inpatient Variation Expenditure Tool (IVET) These tools allow commissioners to compare expenditure and outcomes at disease level. To access these tools visit; These tools are a starting point for the process of making health investment decisions.

28 NHS Comparators NHS Comparators provided by the IC on the NHS net; nww.nhscomparators.nhs.uk Holds data at England, SHA, PCT and Practice level; Data are timely and frequent – every quarter up to Q3 2009/10 Various sources of data including: total admissions – activity and expenditure; non-elective admissions – activity and expenditure elective admissions – activity and expenditure prescribing – items and expenditure better care better value metrics – including low cost statin prescribing Very powerful for showing variation, and time series – which allows to track change over time Outpatient referrals by GP

29 Key Findings

30

31

32 Example SPOT chart – NHS Nottingham City spends more per head on cancer and has a higher premature mortality rate than similar areas. Mortality from all cancers, under 75

33 NHS Oldham Above average overall spend for Musculo Skeletal system problems (MSK) and higher proportion spent on elective admissions Lower health gain for patients receiving hip replacements than patients in PCTs with similar pre-op health status. Patients have relatively low pre-op health status compared to PCTs with similar deprivation levels Average health gain for patients receiving knee replacements compared to patients in PCTs with similar pre-op health status. Patients have relatively higher pre-op status compared to PCTs with similar deprivation levels High FHS prescription rate for MSK Low GP referrals to T&O but high referrals from A&E, MIU & Walk in Centres and average overall T&O outpatient attendances High rate of elective admissions for MSK and long length of stay Low rate of emergency admissions for MSK but long length of stay ….uses Programme Budgeting Tools to show that, when compared to similar PCTs, NHS Oldham has;

34 NHS Western Cheshire The result is that demand for acute services is starting to fall. £7m of the re-investment were delivered in just 6 months. Western Cheshire took a three stage approach to this work: Understanding their current expenditure to identify areas to target Service reviews of identified areas /health programmes Implementation of the agreed recommendations from service reviews Service reviews identified a range of changes specific to each service, including: Service redesign to change a pathway from current to best practice. Contract management or procurement change to get a service provided to a higher quality and/ or lower cost. Decommissioning of a service/pathway because it does not add value or delivers more capacity than is necessary.

35 Derby city and Derbyshire county CCGs Working locally in Derbyshire, Right Care has facilitated the development of 7 “Commissioning for Value Information packs” – soon to be 11, covering Derby city and Derbyshire county CCGs. The packs have been produced with local engagement of CCGs and use both national and local data analysis to generate recommendations for action in 4 programme budget areas. As the Erewash Casebook shows – this has lead to changes in pathways/systems and real cash savings for re-investment Get all these Casebook online at

36 Next Steps Visit the Health Investment Network website: Use the E guides to understand how the tools use in this slidepack work and to gain a better understanding of expenditure and associated outputs and outcomes. Produce versions of this slidepack for other programme budgeting categories. Download the annual population value review which provides a contextual guide to the health investment process. Access a video learning module that explores the definitions, tools and practical application of Programme Budgeting Marginal Analysis (PBMA) Find Useful links to other tools, data sources, reports and guidance. Further information regarding QIPP Right Care can be found at: 36

37 -Subscribe to get a weekly digest of our blog in your inbox -Receive Occasional eBulletins -Follow us on Follow Right Care online